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Claim CLM-1235
Pending
Sarah Johnson • 2025-04-02 • $$850.75
Claim Information
Status
Pending
Claim Type
Institutional
Service Date
2025-04-02
Received Date
2025-04-05
Due Date
2025-04-15
Priority
Normal
Place of Service
Office
Authorization
AUTH-12345
Total Amount
$850.75
Adjudicator
John Smith
Patient Information
Name
Sarah Johnson
Patient ID
PT-56789
Date of Birth
1985-06-15
Gender
Female
Plan
Premium PPO
Member ID
MEM-123456
Group ID
GRP-789012
Eligibility
Active
Provider Information
Name
City Medical Center
NPI
1234567890
Specialty
Family Practice
Network Status
In-Network
Tax ID
12-3456789
Contract Rate
Medicare + 15%
Address
123 Medical Way, Healthcare City, HC 12345
Diagnoses
- E11.9PrimaryType 2 diabetes mellitus without complications
- I10Essential (primary) hypertension
- M25.571Pain in right ankle and joints of right foot
Benefits Information
Plan Details
Effective Date
2023-01-01
Plan Type
Premium PPO
Deductible
Individual/Family
$750/$1,500
Status
Partially Met
Out-of-Pocket
Individual/Family
$1,250/$3,000
Status
Partially Met
AI Assistant
Ask questions about this claim
I've analyzed this claim and found several insights:
codingmedium
Diagnosis code E11.9 (Type 2 diabetes) should be more specific. Consider E11.21 or E11.22 based on documentation.
Potential reimbursement impact: $45-65
documentationlow
X-ray procedure (73630) may require additional documentation to support medical necessity given the primary diagnosis.
Potential denial risk: 15%
complianceinfo
Patient has had 3 office visits in the past 30 days. Consider reviewing for care coordination opportunities.
Care management opportunity